Avoiding urethral and rectal injury during transperineal abdominoperineal resection in male patients with anorectal canc
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Avoiding urethral and rectal injury during transperineal abdominoperineal resection in male patients with anorectal cancer Suguru Hasegawa1 · Ryuji Kajitani1 · Taro Munechika1 · Yoshiko Matsumoto1 · Hideki Nagano1 · Hirotaka Taketomi1 · Akira Komono1 · Naoya Aisu1 · Gumpei Yoshimatsu1 · Mitsuaki Morimoto1 · Yoichiro Yoshida1 Received: 9 August 2019 / Accepted: 14 May 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Background In abdominoperineal resection (APR) in male patients with rectal cancer, high margin involvement and urethral injury have been reported to result from difficulty in dissecting the anterior anorectum. Recently, the efficacy of an endoscopic down-to-up rectal dissection was reported. Here, we present a safe and simple technique for anterior dissection using a simultaneous laparoscopic and transperineal endoscopic approach. Methods We perform transperineal APR (TpAPR) using both the laparoscopic and transperineal approach (a 2-team approach). Anterior dissection commences just behind the superficial transverse perineal muscle. Next, the striated muscle complex surrounding the rectum (levator ani and puborectalis muscle) is divided. At this point, it is difficult to identify the dissection plane between the membranous urethra and anterior rectum; thus, dissection along the lateral aspect of neurovascular bundle from the lateral to anterior side with the assistance of the laparoscopic team is helpful in identifying the posterior surface of the prostate. Once the prostate is identified, it is relatively easy to divide the rectourethralis muscles. The key steps of our procedure are shown in the video. Results Between April 2016 and July 2019, we performed 14 TpAPR procedures in male patients with rectal cancer without distant metastasis. Extended surgery was performed in 8 patients, including pelvic sidewall dissection and combined resection of adjacent organs. Median operative time was 453 min and median blood loss was 46 g. There was 1 (7.1%) circumferentialpositive case, but no cases of urethral injury or rectal perforation. Conclusions The 2-team TpAPR procedure is beneficial for appropriate dissection of the anterior side during APR surgery. Keywords Transanal TME · Rectal cancer · Anatomy The risk of urethral and rectal injury due to the difficulty of dissecting the anterior anorectum cannot be ignored in abdominoperineal resection (APR) [1, 2]. The reported risk of circumferential resection margin (CRM) involvement is higher in APR than sphincter preserving surgery. Novel techniques, such as extralevator abdominoperineal excision [3], have been proposed to achieve negative surgical margins, especially at the anterior aspect [4]. Although this approach Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00464-020-07655-9) contains supplementary material, which is available to authorized users. * Suguru Hasegawa shase@fukuoka‑u.ac.jp 1
Department o
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